Risk factors fpr placental abruption
Prior placental abruption
EtOH or tobacco use
Vascular disease sucha s DM and SLE
Risk factors for placental previa
Advanced maternal age
Hormone changes during menopause
Decrease in estrogen resulting in decrease in the feedback inhibition ont he hypothalamic-pit axis --> elevation of FSH and LH
Menopause how to diagnose in the absence of lab values
12 month history of amenorrhea without other physiologic causes
US reveals solid ovarian tumors, pregnant vs nonpregnant management?
Pregnant - benign luteoma, which usually appears as b/l multinodular solid masses on both ovaries. Replacement of noraml ovarian parenchyma by a solid prolifeartion of luteinzed stromal cells under the influence of HCG... Most common in AA multiparous women in 30s and 40s. Often asymptomatic... but 1/3 develop sx of hirsutism and virilization.... often benign and self limited and requires no treatment.
Nonpregnant --> needs biopsy and aggressive eval, because they are almost always malignant.
Solid ovarian tumors in pregnant
Classic luteoma of pregnancy. Most common in AA multiparous women. Often asymptomatic, but in 1/3 of patients hirsutism and virilization can develop. Benign and self limited, req NO treatment.
2/2 low FSH LH concentrations
Can result from strenuous exercise, anorexia nervosa, marijuana use, starvation, stress, depression, and chronic illness.
FSH and LH drop--> estrogen and testosterone drop --> osteoporosis and decreased muscle mass. Patients will often suffer infertility.
Connection between hypogonadotrophic hypogonadism and hypothyroidism
Can be direct result of hypothyroidism, or be the result of a condition that is also causing hypothyroidism (pituitary pathology).
Atypical endometrial hyperplasia cause
Excessive levels of circulating estrogens or estrogen-like compounds.
Risk factors for gout
Diet rich in purines (organ meats, game, seafood)
NOT at high risk for gout.
Most importnat intervention for preventing spread of HIV from mother to child
Zidovudine treatment (NRTI), aka Azidothymidine, to mother throughout pregnancy and labor, as well as to the neonate for first 6 weeks of life...
Decreases rate of transmission by 70%..
Interventions that decrease mother to infant transmission of HIV
Zidovudine treatment of mother and neonate (70% decrease)
Elective cesarean (50%), combine with above.
Premature ovarian failure characterized by
Elevated serum gonadotropin levels in women age <40 years
Amenorrhea of 3 months duration with FSH in menopausal range
Causes of premature ovarian failure
Accelerated follicular atresia
Low initial number of primordial follicles
Most commonly idiopathic, but may also be due to mumps, oophritis, irradiation, chemotherapy... Can also be associated with autoimmune disorders such as Hashimoto thyroiditis, Addison disease, DM-I, pernicious anemia... this supports diagnosis that some cases of idiopathic premature ovarian failure are of autoimmune origin.
Treatment for infertility with PCOS
Clomiphene citrate (SERM)
Metformin (may also be used to promote ovulationin patients, because insulin resistance seenin this condition may contirbute to inability to ovulate normaly)
TWO most common causes of hypopituitarism in teh postpartum period
1. Sheehan syndrome
2. Lymphocytic hypophysitis (less common)
Lymphocytic hypophysitis: present with
HEadaches, visual disturbances, and pituitary failure. Can be difficult to distinguish from pituitary neoplasm
Sheehan syndrome presentation
In the few months following birth, lethargy, weight gain, fatigue, amenorrhea, dry skin, delayed tendon reflexes........
Aromatase deficiency results in what
Lack of enzymes that converts androgens into estrogens, and thus low estrogens...
In utero, placenta does not make estrogens and thus high level of androgens --> virilization of mother that resolves after delivery... high level of gestational androgens result in virilized XX child with normal internal genetalia but ambiguous external genitalia...
Baby born with clitoromegaly, what is the cause usually
Often seenwhen excessive androgens are present in utero.
Aromatase deificency signs nad sx
Normal internal genitalia
Ambig external genitalia
High FSH/LH w/ low estrogen.
Normal internal genitalia (female) w/ ambiguous external genitalia, low estrogen
Most common cause of CAH
21 hydroxylase deficiency. Also have salt wasting...
Estrogen is still synthesized.
McCune Albright syndrome triad
Cafe au lait spots
Polyostotic fibrous dysplasia
Autonomous endocrine hyperfunction --> gonadotropin independent precocious puberty (early puberty!!)
Hypogonadotropic hypogonadism w/ anosmia
Delayed puberty but low or absent LH and FSH levels
Galactose-1-phosphate uridyltransferase deficiency
Galactose-1-phosphate accumulation i nliver, brain, kidney --> cirrhosis, mental retardation, and Fanconi syndrome
Vulvar skin is thin, dry, and white in color
Lichen sclerosus (lichen sclerosus et atrophicus), an autoimmune phenomenon...
Anogenital discomfort with pruritus, dyspareunia, dysuria, and painful defecation..
Long term effects of Lichen sclerosus
Sclerosus and scarring --> obliteration of the labia minora and clitoris and a decrease in the diameter of the introitus.
Vulvar SCC -->occurs more commonly in women w/ LS&A. Punch biopsy of any suspicious lesions should be performed.
Estrogen cream good for what
Menopause-related atrophic vaginitis, which can also be a cause of vaginal pruritus and dyspareunia
Treatment of lichen sclerosus et atrophicus
Considered a premalignancy, so surveillance with reg clinical exams and biopsies
High potency steroids (few conditions for which this is encouraged), because it is a chronic inflammatory condition.
Presence of feto-maternal hemorrhage, what test?
Rosette test.... Treat matenral blood with anti-Rh, then R2R2 cells.
If negative administer anti-D immune globulin as per usual.
If positive, amount of hemrorhage can be evaluated with a Kleihauer-Betke stain or fetal red cell stain using flow cytometry and the dose of Anti-D immune globulin should be adjusted accordingly.
When should standard dose of Anti-D be administered in an uncomplicated pregnancy
28 weeks, again at delivery. Risk of alloimmunization before 28 weeks is very low.
Amniotic fluid embolism is a well recognized complication of what
Amniocentesis. Presents with sudden respiratory failure, is often accompanied by cardiogenic shock and seizures.
Immediate management of amniotic fluid embolism
Adequate respiratory support. Facemask ventilation, or intubation.
Symptoms in endometriosis
When sx: chronic pelvic pain that is worse in premenstrual period, dysmenorrhea and pain with sexual intercourse or defecation. Exam: rectovaginal tenderness or tenderness with mvoement of the uterus due to presence of ecotpic endometrial tissue in the rectovaginal septum and pelvic peritoneum... blah blach blach.
Connection between infertility and endometriosis
Up to 30% of females being evaluated for infertility are found to have endometriosis
Mechanisms for infertility in endometriosis
Adhesion formationw/i peritoneum that interferes wtih the normal transfer of oocytes from the ovaries to the fallopian tube
Endometrial factors within uterus that may provide suboptimal environment for implantation
Hormonal stuff that have yet to be determined
Risk factors for endometrial cancer
Use of unopposed estrogen in the past
Prolonged use of tamoxifen
aka Multiple hamartome syndrome
Increase in hamartomas, and increased risk of certain forms of cancer....
Loss of function mutation in PTEN, a TSG that leads to hyperactivity of mTOR...
Cowden syndrome s/sx
Intestinal hamartomatous polyps
Dysplasti gangliocytoma of the cerebellum --> Lhermitte-Duclos disease
Cowden syndrome, predilection to what cancers
Follicular carcinoma of the thyroid
Risk for preterm labor
Prior preterm labor
Premature rupture of membranes
Exposure to diethylstilbestrol
Dysfunctional uterine bleeding, how to diagnose
Heavy vaginal bleeding that occurs in the absence of structural or organic disease... normal pelvic exam + negative pregnancy test --> DUB.
Steps in the w/u for DUB
Endometrial biopsy, to r/o endometrail hyperplasia or carcinoma....
Esp in >35 yo, obese, chronically hypertensive, or diabetic...
Risk factors for endometrial hyperplasia or carcinoma
Treatment for DUB
Screen those with risk factors for endometrial business
Cyclic progestins... if that fails, endometrial ablation or hysterectomy.
Corticosteroid treatment for what GA
No benefit after 34 weeks, use is limited to 24-34 weeks. Additionally corticosteroids require 24-48 hours to have maximum benefit on fetal lung maturity
Pelvic exam in atrophic vaginitis
Pale, dry,and smooth vaginal epithelium
Scarce pubic hair
Loss of labial fat pad....
This results from decrased estrogenlevelss.
Treatment for atrophic vaginitis
Mild - lotions, moisturizers
Mod-severe - low dose vaginal estrogen therapy
How to assess infertility due to aging
Early follicular phase FSH level
Clomiphene challenge test
Signs of premature ovarian failure
Amenorrhea, can also be caused by autoimmune conditions, heritable factors, exogenous factors such as radiation exposure, and as an idiopathic condition.
Clinical: hirsutism, acne, or male pattern baldness or androgenic alopecia and/or biochemical high serum androgen concentrations
Amenorrhea or oligomenorrhea
Pelvic U/S with cystic ovaries, small cysts are noted around the ovaries in a classic "string of pearls" appearance.
Pelvic U/S with cystic ovaries
Small cysts are noted around the ovaries in a classic "string of pearls" appearance
PCOS risks for what
Causes of severe vomiting during pregnancy
Gestational trophoblastic disease (hydatidiform mole and choriocarcinoma)
Clinical course of hyperemesis gravidarum
Vomiting begins in weeks 4-10
GEnerally resolfves by mid pregnancy
Hyperemesis gravidarum diagnostic factors
Persistence of vomiting
Loss of >= 5% prepregnancy weight
Diff diagnosis for hyperemesis gravidarum
Gestational trophoblastic disease
Gestational trophoblastic disease
PCOS risk for what
Adequate amount of active estrogens. Androgens will be converted into estrogens in the peripheral tissues. Deficient in progesterone secretion, and thus constant and unbalanced mitrogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia, intermittent breakthrough bleeding, and dysfunctional uterine bleednig.
PID criteria diagnosis
Purulent cervical discharge
Cervical motion tenderness
Lower abdominal tenderness
Maternal opioid abuse
Withdrawal symptoms in the infants following birth --> irritability, tremors, vomiting, diarrhea, and salivation. Long-term CNS deficits in these infants and an increased risk of SIDS
Uncontrolled maternal DM
Cardiomyopathy among other possible findings
Fetal alcohol syndrome, typical findings
Short palpebral fissures
Thin upper lip
Effective up to 120 hours post intercourse, but effectiveness is greater the earlier the medication is administered.
Effectiveness of the plan B
7 out of 8 women who would have otherwise become pregnant from intercourse.
Diff dx for hyperemesis gravidarum
Gestational trophoblastic disease
PCOS deficient in what
Progesterone secretion, thus they have constant and unbalanced mitogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia
Fetal alcohol syndrome s/sx
Facial dysmorphology: midfacial hypoplasia, micrognathia, flattened (smooth) philtrum, microphthalmia, short palpebral fissures, thin upper lip
CNS damage: irritability, ADHD, learning disabilities, frank mental retardation
Symptoms of withdrawal in an infant
Long term CNS deficits wtih increased risk of SIDS
Uncontrolled diabetes maternal-fetal effects
Breech presentations <37 weeks, usual fates?
Self-correction by the 37th week of gestation, thus no external version is recommended before that time.
Contraindications to external version for breech positioning
Hyperextended fetal head
When should screening for GDM take place
High risk: first prenatal visit
Others: 24-28 weeks
One hour 50g OGTT used as initial screening. If <140, GDM ruled out... If >140, three hour 100g OGTT is then performed
One hour serum glucose >180
Two hour serum glucose >155
Three hour serum glucose >140
Androgen insensitivity syndrome
Testicular feminization --> defect or absence of androgen receptors resulting in androgen resistance of all peripheral tissues... Female phenotype with a 46XY. Still normla testes that are typically found in the abdomen or inguinal canal, and patients are prone to inguinal hernias....
MIF produced by testes, and prohibits formation of the uterus, fallopian tubes, and upper portion of vagina...
Breasts develop because of peripheral conversion of testosterone to estrogen, whereas axillary and puibic hair does not develop since it is dependent on testosterone.
Treatment: Testicular resection, creation of a neovagina.
Primary amenorrhea and nondeveloped internal reproductive organs,but normla XX karyotype with normal testosterone.... Normal axillary and pubic hair development since they respond appropriately to testosterone.
Sx of androgen resistance
Normally developed breasts
Absent pubic and axillary hair
Absent internal organs
Who gets granulosa cell tumors
Bimodal age distribution.
Young - Precocious puberty
Old - Postmenopausal bleeding, uterine myohyperplasia, absence of vaginal atrophy
S/Sx of dysgerminoma
Neutral hormone-wise, may arise in younger women or children, average incidence 20.
Occasionally they undergo torsion
S/Sx of sertoli-leydig cells
Androgen producing, causes defeminization followed by masculinization. May have altered body contour, flattening of breasts, scanty/irregular menstruation, ultimately ending in amenorrhea....
Hirsutism, coarsening of the features, enlargement of the clitoris.
Most common cystic ovarian neoplasms
Serous cystadenomas - 30% of all ovarian tumors. 25% of all these are malignant, and about half of the cases are bilateral. Usually do not produce estrogen or androgens...
Ovarian mass and abdominal pain are presenting features.
Chorionic villus sampling can be done when
10-12 weeks gestation....
Indicated in women over 35 yo with an abnormal US.
Slightly higher risk than amniocentesis
When is amniocentesis done
16-18th weeks gestation
There is also early amniocentesis<15weeks, reserved for those who cannot have chorionic villus sampling.
What is codocentesis
aka Percutaneous Umbilical Blood Sampling.... used for rapid karyotype analysis or when fetal blood dyscrasias such as fetal anemia and Rhesus isoimmunization are suspected.... Also for when mosaicism is suspected by CVS or amnio to further assess the fetal karyotype.
MSAFP good for screening for what
Neural tube and abdominal wall defects
Chromosomal anomalies when serum levels of estriol and bHCG are also assessed....
Risks of CVS
Limb reduction defects
Limb reduction defects are greatest when procedure is done before nine to ten weeks gestational age...
Diethylstilbestrol exposure in utero predisposes to what in female offspring
Cell cell adenocarcinoma of vagina and cervix
Cervical abnormalities (hypoplasia)
Uterine malformations (T-shaped, small uterine cavity)
Vaginal adenosis and vaginal septae
Many also have difficulty conceiving and maintaining pregnancy.
DES what is this
Diethylstilbestrol, used between 1947-1971 for the treatment of threatened abortion... Female offspring of treated women have higher risk of clear cell adenocarcinoma of the vagina and cervix among other thigns
Diethylstilbestrol predisposes male offspring to what
Risk factors for endometrial cancer
Chronic unopposed estrogen use (PCOS??)
Chronic TAMOXIFEN use
Differential diagnoses for adenomyosis
All can present with dysmenorrhea, menorrahgia and a large sized uterus
>35? Endometrial curettage to r/o endometrial carcinoma.
Enlarged and tender uterus
Foul smelling vaginal discharge
Usually occurs after a septic abortion or in the postpartum period (puerperal fever)
Who gets adenomyosis typically?
Multiparous women >40 yo. Typically presents with dysmenorrhea and menorrhagia. PE reveals enlarged and generally symmetrical uterus...
DDx; fibroids, but this is irregularly shaped uterus.
Indications for GBS prophylaxis when GBS status is unknown
Duration of membrane rupture >=18 weeks
GBS bacteriuria in any concentration during current pregnancy
PHx of previous delivery of infant with GBS sepsis
PCN during labor
Alternatives: ampicilling, cefazolin, clindamycin, or vancomycin...
Tocolysis in the setting of PPROM
Short term, so that glucocorticoids can be given to promote fetal lung maturity.. usually <32 weeks gestation, often 32-34, but never >=35 weeks
When is injection of dye into the uterus helpful
Early early PPROM, when ROM is difficult to confirm. PPROM early on may commit pregnant woman to long term bedrest.
Antenatal corticosteroids, when typically
<32 weeks gestation.
Prevents neonatal RDS, necrotizing enterocolitis, neonatal intraventricular hemorrhage, and neonatal death....
Beyond 32 weeks, hard to tell... though many centers continue to administer bethamethasone at gestational ages b/w 32-34 weeks for patients with PPROM. Glucocorticoids are typically not given after 34 weeks.
Most common type of precocious puberty
Idiopathic central precocious puberty, resulting from premature activity of H-P-G axis... They have pubertal levels of basal LH that increase with GnRH stimulation, whereas patients with peripehral source have no stimulation+ test....
What is Cyproterone acetate
Steroid-based compound with antiandrogenic and antigonadotropic effects, used in Europe second line for hirsutism.
Inhibits secretion of gonadotropins, used for contraception and abnormal uterine bleeding.
GDM pregnancy risks
GDM effectson the fetus
Hyperviscosity due to polycythemia
Why polycythemia in infant born to diabetic mother?
Fetal hypoxia which occurs in face of increased basal metabolic rate induced by hyperglycemia. Increased EPO production by the fetus increases RBC mass and oxygen carrying capacity of the blood.
Inevitable abortion characterized by what?
Vaginal bleeding, fluid discharge
Lower abdominal cramps
Dilated cervix through which POCs can occasionally be visualized.
U/S --> ruptured or collapsed gestational sac and absence of fetal cardiac motion.
Any hemorrhage occurring before 20th week gestation with a live fetus... Cervix closed, no passage of fetal tissue. Mild lower abdominal pain may be noted. FHR active on U/S.
Molar pregnancy characterization
1st trimester vaginal hemorrhage assoc with expulsion of vesicles (villi), excessive nausea and vomiting, and uterine size greater than dates.
U/S --> snow storm appearance with no FHR or identifiable fetal structures, and bHCG markedly increased.
Fetus expires in utero, but the POCs are not discharged from the uterus spontaneously. Patients present with loss of pregnancy sx and no continued increase in uterine size.
Ab pain and cramping
Vaginal bleeding and passage of tissue from the uterus, on exam: cervix is closed and US demonstrates an empty uterus.
Sx of trich
Green, frothy, foul smelling vaginal discharge
Urinary symptosm or dyspareunia as well
Some women are completely asymptomatic!
Also Candida vaginitis and BV can present similarly.
Treatment for Trichomonas
Metronidazole for person and partner. Oral! Affected males are usually asymptomatic.
When should pregnant women be syphilis treated
First prenatal visit (RPR or VDRL).
Then confirm with Fluorescent Treponemal Antibody Absorption test (FTA-ABS).
USPSTF recommendations for chlamydia testing
All women 24 and younger
Hx of STDS,new or multiple partners
Hypogonadotropic hypogonadism due to what
Severe life stressors
Insufficient pulses of GnRH from hypothalamus causes pituitary LH and FSH production to decrease.
Continuous GnRH therapy for whom
Children with precocious puberty (GnRH dependent)
Men and women with sex hormone-dependent tumors.
Severe preeclampsia definition
Presence of one or more of:
- AMS, headache, scotoma, blurred vision
- PulmEdema, cyanosis
- Epigastric or cyanosis
- Significant thrombocytopenia
- Microangiopathic hemolysis
- Altered LFTs
- Elevated serum creatinine
- IUGR or oligo
Mech of eclamptic seizures
Cerebral vasospasm --> cerebral hypoxemia and generalized tonic clonic seizures. Can be thought of as a specialized subset of hypertensive encephalopathy that occurs in the setting of preeclampsia.
What usually heralds the occurence of seizures in patients with preeclampsia
Increased reflex irritability
Suspect chorioamnionitis in whom
PPROM, or prolonged premature rupture of membranes
Maternal tachycardia (>100)
Fetal tachycardia (>160)
Maternal leukocytosis (>15k)
Uterine tenderness or foul smelling amniotic fluid
Interventions for chorioamnionitis
Broad spectrum antibiotics
Induction of labor (oxytocin??)
If fetal distress --> consider caesarian delivery.
Single most useful parameter for predicting fetal weight?
Abdominal girth - affected in both symmetric and asymmetric fetal growth restriction
Symmetric vs asymmetric fetal growth restriction
Symmetrical - usually insult <28 weeks gestation, and growth of both head and body is deficient. TORCH or genetic stuff
Asymmetric - >28 weeks, results from other thungs... insults after this time.
When is FGR suspected
Fundal height at least 3cm less than the actual gestational agein weeks, confirmed via US
Post-term pregnancy problems
Any pregnancy at or beyond 42 weeks --> BIW U/S required to evluate for oligohydramnioas b/c amniotic fluid can become drastically reduced within 24-48 hours....
Risk factors for abruptio placentae
Uncontrolled maternal hypertension
Maternal cocaine use
History of prior episodes of placental abruption
Risk factors for placenta previa
Advancing maternal age
Prior cesarian section
Preeclampsia risk factors
Extremes of maternal age
Collagen vascular diseases
Baseline uncontrolled maternal hypertension
FHx of preeclampsia
Earliest sign of mag toxicity
Mag causes CNS depresion by blocking neuromuscular transmission. Regular exam with DTRs is mandated.
Definition of threatened abortion
Any hemorrhage from uterine cavity occurring before the 20th week of gestation with a live fetus.
Vaginal bleeding, lower abdominal cramps, dilated cervix. US --> ruptured or collapsed gestational sac with absence of fetal cardiac motion.
Semen analysis in infertility, when should it occur
Early in the evaluation of the infertile couple. Accounts for 20-30% of infertility causes. And a relatively simple test.
How to evaluate anovulation as a potential cause of infertility
Basal body temp
Serum progesterone measurement in mid-luteal phase.
Management of inevitable or incomplete abortions
Hospitalization, observation for sepsis, DIC, and extensive hemorrhage
ASCUS + CIN-I
Repeat Pap smear in 6-12 months
HPV testing in 12 months
Either of these are weird? Colposcopy. If persistent colposcopy changes --> diagnostic excisional procedure to rule out high grade lesions.
Most common clinical finding of abruptio placentae
Dark, red, third trimester vaginal bleeding - 80% of cases. Thus can be concealed in 20% of cases --> only sx may be uterine tenderness, hyperactivity, and increased uterine tone.
What is the role of US in evaluation of antepartum hemorrhage
Primarily to rule out placenta previa.
Previa - uterus is NONTENDER.
Risk factors for abruptio placentae
Maternal hypertension and preeclampsia
Placental abruption in a previous pregnancy
Rapid decompression of a hydramnios
Short umbilical cord
Tobacco use and cocaine abuse
Rare --> fetal blood vessels traverse the fetal membranes across the lower segment of the uterus between the fetus and the internal cervical os..
Presents wtih painless antepartum/intrapartum hemorrhage assoc with rapid deterioration of the fetal heart tracing.
What precedes uterine rupture
Preceded by agitation, hyperventilation, tachycardia. Rupture is rare and most often a problem during active labor, not during the antepartum period.
Risk factors for cervical insufficiency
Prior gyn surgery esp LEEP or cone biopsy, elective abortion
Prior ob trauma
Mullerian anomalies and a history of preterm birth or a second trimester pregnancy loss
Risk factors for polyhydramnios
Risk factors for abruptio placentae
Hx of external cephalic version
SGA risk factors
Impaired placental perfusion
Alcohol or drug abuse
Gold standard for cervical eval
Transvaginal ultrasound - presence of funneling of cervix or shortening of the cervical length - should be more than 25 mm at 24 weeks..... <10th percentile - short cervix.
Most common cause of nonreactive NST
Sleeping baby, not a diseased baby. Vibroacoustic stimulation used to wake up baby.b
US detection of abruption
Only detects 25% of cases
More useful in ruling out placenta previa than in diagnosing abruption
Ovulatory phase mucus changes
Profuse, thin, clear. Stretches to approx 6cm when lifted vertically (spinnbarkeit). pH is 6.5 or greater and it will demonstrate ferning as well.
Young women presents with a breast lump, can ask to do what
Return after her menstrual period for reexamination if no obvious signs of malignancy are present. If it decrease in size after the menstrual period, probability of benign disease is very high.
When is ECV indicated
B/w 37 weeks and the onset of labor. Has been shown to reduce the rate of cesarean sections.
Risk of ECV
Potential to result in fetal distress, so it should only be performed when arrangements have been made to allow for an emergent cesarian delivery.
What is internal podalic version
Converting the second twin in a twin deliery from a transverse or oblique presentation to a breech presentation for subsequent delivery.
Lichen sclerosus presentation
Thin, white, and wrinkled skin over the labia, typically affecting postmenopausal females
Vulvar lichen planus presentation
Middle-aged women, lesions may be hyperkeratotic, erosive, or papulosquamous in appearance.... Pruritus, soreness, and vaginal discharge are common.
When do variable decels transition from intermittent to variable
Repetitive >=50% in a 20 minute period.
First step in NRHR
Change maternal positioning
Also d/c uterotonic drugs, and eval/treat maternal hypertension.
Perhaps consider amnioinfusion for variable decels
Fetal scalp pH for what
Fetal hypoxia, if the abnormal FHR pattern persists after initial measures of position change, oxygen administration, and d/c of oxytocin have been tried.
Transab vs transvaginal U/S for the evaluation of gestation
Transab cannot reliably visualize until betaHCG >6500
Transvag can see as low as 1500 bHCG, sometimes even as low as 800
What use are serial bHCGs for ectopics?
bHCG should double every 48 hours... if it doesnt, if it has a slower rise --> bHCG
Culdocentesis, what is this
Insertion of needle into the posterior vaginal wall to identify peritoneal fluid in the cul de sac.
Septic retained POC, treatment
Cervical and blood cultures
Gentle suction curettage (vigorous curettage please avoid b/c of risk of uterine perforation)
This is a medical emergency.
Pregnancy not at term, mild preeclampsia
Bed rest and close observration
HTN usually responds, but methyldopa can be used to treat sustained BPs in excess of 160/110
Dexamethasone 24-34 weeks gestation should be considered
Fetal hydantoin syndrome
Can be caused by exposure to many anticonvulsants, most commonly phenytoin and carbamazepine
Cleft lip and palate
Congenital syphilis signs/sx
Like FHS: midfacial hypoplasia, microcephaly, stunted growth
CNS damage, which may manifest as hyperactivity, MR, or learning diasbility..
NO CLEFT PALATE OR EXCESS HAIR.
Vaginal cancer treatment
Stage I and II (no extension to pelvic wall, no mets) <2 cm in size - removed surgically
Stage I and II >2 cm size - radiation therapy
Stage III and IV - combo chemotherapy, as well as tumors >4 cm in size...
Preterm labor def
Labor >20 weeks and before 37 weeks.
Labor contractions >4 / 20 minutes or mroe and documented cervical changes consistent with labor.
Complications of preterm birth
Necrotizing enterocolitis and kernicterus
Mortality is greatly influenced by gestational age.
Tocolysis in preterm labor
At least 48 hours in order to reach maximum benefit. But bedrest and tocolysis for as long as possible with a long term goal of reaching 34-36 weeks of gestation.
Cerclage for what
Treat or prevent first trimester abortions when the cause is an incompetent cervix.
Causes of low levels of MSAFP
Chromosomal abnormalities (down and trisomy 18)
Inaccurate gestational dates
Thus, for low levels of MSAFP, do US to rule out inaccurate dates. You can then move on to other causes after the dates have been confirmed by US.
Cordocentesis used for what
Rapid karyotype analysis
or when fetal blood dyscrasias, such as fetal anemia and Rhesus isoimmunization, are suspected.
Uterine rupture vs abruptio placenta due to trauma
Uterine rupture much more likely to cause signs of hypovolemia and shock due to rapid exsanguination.
What is vasa previa
Rare condition in which fetal blood vessels traverse the membranes acrosst he lower segment of the uterus b/w the fetus and the internal cervical os.
How might vasa previa present
Painless antepartum hemorrhage assoc with rapid deterioration of the fetal heart tracing as it is fetal blood that is being lost in this condition.
Causes of premature ovarian failure
Autoimmune ovarian failure
Fragile X syndrome
Sx of premature ovarian failure
Vaginal and breast atrophy
Psychologic symptoms such as anxiety, depression, and irritability
What confirms diagnosis of premature ovarian failure
Markedly elevated FSH level in a wwoman under age 40 who has experienced >=3 months of amenorrhea --> confirms diagnosis of premature ovarian failure.
What cancers decrease with use of OCPs
Endometrial and ovarian cancer
Benign breast disease
OCP risk of insulin resistance
Present but very very mild. OCPs have NOT been shown to precipitate diabetes in non-diabetic patients.
Modifiable risk factors for OP
Hormonal factors such as low estrogen levels
Use of certain medications such as glucocorticoids or anticonvulsants
Excessive alcohol consumption (dose dependent)
Non-modifiable risk factors for OP
Small body size
Late menarche/early menopause
Caucasian or asian
FHx of OP
ABO incompatibility, what pregnancy
First, because these antigens are found in the environment. But varying degress of antibody production and thus varying levels of usually minor disease.
ABO incompatibility usually manifests how
Hemolytic disease of the newborn, less severe though than RhD incompatbility.
Risk factors for endometritis
PROM >24 hours
Prolonged labor >12 hours
Use of utrauterine pressure caths or fetal scalp electrodes
Endometritis common cause
Polymicrobial, thus treat with clinda (gram neg and anaerobes) and gent (gram positives)
Postpartum endometritis due to Chlamydia?
Uncommon, occurs many days following delivery, not in the first 48-72 hours.
Treatment of asymptomatic bacteriuria of pregnancy
First gen cephalosporin for 7 days
Risks of asymptomatic bacteriuria in pregnancy
Low birth weight
Increased perinatal mortality
Young patient with heavy menses and irregular cycles
Anovulatory cycles... females in this age group have an immature hypothaalmic-pituitary-ovarian axis that may fail to produce gonadotropins in proper quantities to induce ovulation..... up to 90% of all menstrual cycles in first year after menarche may be anovulatory.
How to PCN desensitize
Incremental doses of oral PCN-V
PCN is important because it crosses the placenta. Using erythromycin would not work, e.g., for that very reason.
What is pseudocyesis
"False pregnancy," considered a form of conversion disorder in which a woman who is trying to become pregnant comes in with sx of pregnancy such as amenorrhea, enlargement of breasts and abdomen, morning sickness, weight gain, sensation of fetal movement, report of positive HCG. Pregnancy eval such as US will reveal normal endometrial stripe and HCG testin office will be negative.
Graves disease and pregnancy
In many patients, circulating level sof TSI remain as high as 500x normal value for several months following thyroidectomy. These are IgG and thus can cross the placenta
Characteristics of neonatal thyrotoxicosis
Poor weight gain in infant
Typically w/i 1-2 days following delivery.
Down and Edward syndrome on quadruple screen
Down - low MSAFP, low estriol, elevated bHCG, elevated inhibin A.
Edward - low MSAFP, low estriol, very low bHCG, normal inhibin A
Risk factors for placenta previa
Advanced maternal age
Uterine rupture presentation
Sudden onset of intense abdominal pain, vaginal bleeding assoc with hyperventilation, agitation, and tachycardia.
Connection between hypothyroidism and prolactin
Hypothyroidism increases TRH, which stimulates prolactin production.
Prolactin production, inhibition and stimulation
Inhibited by dopamine
Stimulated by serotonin and TRH
Drugs that cause high prolactin levles
Those that include dopamine antagonists: antipsychotics, TCAs, MAOIs...
How does amenorrhea work in lactating mothers
High levels of circulating prolactin ----| GnRH...
Still not reliable method of birth control. In fact 50% of nursing mothers ovulate w/i 6-12 months of delivery.
What is Human placental lactogen
Produced by placneta, has insulin antagonist effects ahd plaays an important role in nutrition of the fetus by causing maternal lipolysis and insulin resistance, thus increasing delivery of fatty acids and glucose to the fetus.
Milk production activated by what
Sudden decrease in estogren and progesterone.
Release of prolactin and oxytocin through stimulatory effect of suckling.
Lactation suppression, how to
Tight fitting bra
Avoidance of nipple stimulation or manipulation
Ice packs/analgesics for pain
No role of meds for the suppression of milk production. Bromocriptine has too many side effects.
Missed abortion, when to suspect
Loss of nausea and vomiting of early pregnancy
Arrest of uterine growth...
Sx of hydatiform mole
1st trim vaginal bleeding
Expulsion of villi
US --> snow storm appearance, serum bHCG levels are increased.
Any hemorrhage occurring before 20th week gestation with a live fetus. Cervix closed, no passage of fetal tissue.
Lower ab cramps --> radiate to back and perineum
Same as incomplete abortion but incomplete evacuation of conceptus. U/S -> endometrial debris.
PCOS results from what
Abnormal GnRH secretion that stimulates pituitary to secrete excessive LH and insufficient FSH... excess LH sitmualte androgen production by ovarian theca cells resulting in hirsutism, etc. Anovulation caused by imbalance between LH and FSH production and in part insulin resistance in these patients
Progesterone produced by what
Corpus luteum following ovulation. Withdrawal of progesterone --> menses.
Rupture fetal umbilical vessel sx
Antepartum hemorrhage with very characteristic fetal heart rate changes --> Tachycardia to bradycardia to a sinusoidal pattern.
Abruptio placentae type of bleeding
Dark red antepartum hemorrhage along with abdominal pain, uterine tenderness, and increase uterine tone. Bleeding is of maternal origin.
Polyhydramnios effect on mother
Result of compression of lungs, abdominal organs, and vasculature. Difficulty breathing and lower extremity edema are common.... Placental abruptiona nd PPH due to uterine atony are associated with hydramnios.
FHT --> sinusoidal pattern directly after rupture
Think Vasa previa or some other loss of fetal blood.
Maternal vital signs will be fine while the fetus exsanguinates.
Elevated liver enzymes
Possibly pulmonary edema
Eclampsia defined as what
Occurrence of grand mal seizures in patients with either mild or severe preeclampsia.
Why is furosemide CI in pregnancy
Diuretics can inhibit the normal physiologic intravascular volume expansion that occurs as a normal function of pregnancy.
Involuntary contraciton of perineal musculature making vaginal penetration tough and painful. Underlying cause is psychological. Patients often have had strict religious upbringings in which sex was either not discussed or discussed in a negative fashion, have had trauma of childhood.
Treatment for vaginismus
Insertion of dilators, fingers, etc. to bring about desensitization.
IUGR two broad divisions
Symmetric - fetal factors, usually before 28 weeks
Asymmetric - maternal factors, usually after 28 weeks when the head has grown.
Asymmetric IUGR causes
- Fetal redistribution of blood flow to vital organs, at the expense of the viscera.
- Maternal HTN
- Uterine anomalies
- Maternal antiphospholipid syndrome
- Collagen vascular disease
- Maternal cig smoking
Symmetric IUGR causes
- Chromosomal abnormalities
- Congenital anomalies
- Congenital infections --> TORCH
Renal plasma flow during pregnancy.
Increase in renal function begins early in first trimester, progresses gradually until reaching 40-50% above non-pregnant state by mid-pregnancy, and remains unchanged until term.
Premenopausal women with simple or complex endometrial hyperplasia w/o atypia
Typically they respond to Cyclic progestins.... Risk of progression to endometrial cancer is low <3%.
Also need repeat biopsy in 3-6 months.
Eval of primary amenorrhea...
Absent --> Karyotype, serum testosterone
Present --> FSH... increased --> karyotype, decreased --> cranial MRI
Major source of estrogen in menopausal women
Peripheral conversion of adrenal androgens by aromatase in adipose tissue.
Clomiphene what is this
Estrogen analog (SERM) that improves GnRH release and FSH release thus improving chances of ovulation.
post ovulation, progesterone primary peak, estrogen secondary peak.
Defects - progesterone replacement.
Treatment of BV in pregnancy
Actually same as that for BV normally, so oral metronidazole 500mg BID x 7 days.
Vaginal metro or clinda are alternatives.
Macrolides that are safe in pregnancy
Azithromycin. NOT Erythromycin because it may cause acute cholestatic hepatitis.
Three D's of endometriosis
Other features - pelvic pain, infertility.
Four pain symptoms
Two GI symptoms
One sexual symptom
One pseudoneurologic symptom
Medical causes of dyspareunia
Vulvar or vaginal growths
Arrest of descent definition
Lack of change (fetal presenting part) in 2 hours for primigravid patients
1 hour for multigravid
Add an extra hour if an epidural is in place.
Findings suggestive of cephalopelvic disproportion
Increased molding of fetal skull
Prominent ischial spines
Last resort in cause of shoulder dystocia
Consists of pushing baby back into the uterine cavity followed by a ceasarian section.
Problems in power with arrest of descent
Normal features of postpartum period that may initially be alarming
Low grade fever
Chills (intrapartum and postpartum)
Trich vaginitis vs BV
Trich - sexually transmitted infection that causes malodorous gray-green thin, frothy vag discharge, as well as vaginal and vulvar pruritus, dysuria, and dyspareunia. Pruritus and inflammation, strawberry cervix.
BV - Usually no pruritus, no inflammation.
What is pelvic congestion syndrome
Varicose veins in the lower abdomen, manifesting in chronic pain which is dull ache. Larger tuerus and thicker endometrium but not outside realm of neomral.
Turner syndrome cause of infertility
Ovarian dysgenesis, restling in low estrogen levels and inability to menstraute...
Basically premature menopause, with the poor ovarian function causing FSH levels to be high due to lack of negative feedback.
False labor vs real labor
False - contractions in lower abdomen, irregular, occur at an interval that does not shorten and do not increase in intensity.
Last month --> may become rhythmic, every 10-20 minutes.
Usually do not progress, and are usually relieved by sedation.